Resistance exercise, disability, and pain catastrophizing in obese adults with back pain

PURPOSE

The purpose of this study was to compare the effects of two different resistance exercise protocols on self-reported disability, fear avoidance beliefs, pain catastrophizing, and back pain symptoms in obese, older adults with low back pain (LBP).

METHODS

Obese adults (n = 49, 60-85 yr) with chronic LBP were randomized into a total body resistance exercise intervention (TOTRX), lumbar extensor exercise intervention (LEXT), or a control group (CON). Main outcomes included perceived disability (Oswestry Disability Index, Roland Morris Disability Questionnaire). Psychosocial measures included the Fear Avoidance Beliefs survey, Tampa Scale of Kinesiophobia, and Pain Catastrophizing Scale. LBP severity was measured during three functional tasks: walking, stair climbing, and chair rise using an 11-point numerical pain rating scale.

RESULTS

The TOTRX group had greater reductions in self-reported disability scores due to back pain (Oswestry Disability Index, Roland Morris Disability Questionnaire) compared with those in the LEXT (P < 0.05). The Pain Catastrophizing Scale scores decreased in the TOTRX group compared with that in the CON group by month 4 (64.3% vs 4.8%, P < 0.05). Pain severity during chair rise activity and walking was decreased in both the LEXT and TOTRX groups relative to the CON group.

CONCLUSIONS

Greater reductions in perceived disability due to LBP can be achieved with TOTRX compared with those achieved with LEXT. Pain catastrophizing and pain severity decreased most with TOTRX. The positive change in psychological outlook may assist obese, older adults with chronic back pain in reconsidering the harmfulness of the pain and facilitate regular participation in other exercise programs.

Kinematic, Cardiopulmonary, and Metabolic Responses of Overweight Runners While Running at Self-Selected and Standardized Speeds

OBJECTIVE

To determine the differences in kinematic, cardiopulmonary, and metabolic responses between overweight and healthy weight runners at a self-selected and standard running speed.

DESIGN

Comparative descriptive study.

SETTING

Tertiary care institution, university-affiliated research laboratory.

PARTICIPANTS

Overweight runners (n = 21) were matched with runners of healthy weight (n = 42).

METHODS

Participants ran at self-selected and standardized speeds (13.6 km/h). Sagittal plane joint kinematics were captured simultaneously with cardiopulmonary and metabolic measures using a motion capture system and portable gas analyzer, respectively.

MAIN OUTCOME MEASUREMENTS

Spatiotemporal parameters (cadence, step width and length, center of gravity displacement, stance time) joint kinematics, oxygen cost, heart rate, ventilation and energy expenditure.

RESULTS

At the self-selected speed, overweight individuals ran slower (8.5 ± 1.3 versus 10.0 ± 1.6 km/h) and had slower cadence (163 versus 169 steps/min; P < .05). The sagittal plane range of motion (ROM) for flexion-extension at the ankle, knee, hip, and anterior pelvic tilt were all less in overweight runners compared to healthy weight runners (all P < .05). At self-selected speed and 13.6 km/h, energy expenditure was higher in the overweight runners compared to their healthy weight counterparts (P < .05). At 13.6 km/h, only the frontal hip and pelvis ROM were higher in the overweight versus the healthy weight runners (P < .05), and energy expenditure, net energy cost, and minute ventilation were higher in the overweight runners compared to the healthy weight runners (P < .05).

CONCLUSION

At self-selected running speeds, the overweight runners demonstrated gait strategies (less joint ROM, less vertical displacement, and shorter step lengths) that resulted in cardiopulmonary and energetic responses similar to those of healthy weight individuals.

Effect of neurocognition and concussion on musculoskeletal injury risk

Research regarding musculoskeletal injury risk has focused primarily on anatomical, neuromuscular, hormonal, and environmental risk factors; however, subsequent injury risk screening and intervention programs have been largely limited to neuromuscular factors and have faced challenges in both implementation and efficacy. Recent studies indicate that poor neurocognitive performance, either at baseline or in the aftermath of a concussion, is associated with elevated risk of musculoskeletal injury. Despite the relatively limited current understanding regarding the nature of the relationship between different aspects of neurocognitive performance and musculoskeletal injury risk, this is a promising area of research that may yield significant advances in musculoskeletal injury risk stratification, rehabilitation, and prevention.

Chronic pain management in the obese patient: a focused review of key challenges and potential exercise solutions

In obese persons, general and specific musculoskeletal pain is common. Emerging evidence suggests that obesity modulates pain via several mechanisms such as mechanical loading, inflammation, and psychological status. Pain in obesity contributes to deterioration of physical ability, health-related quality of life, and functional dependence. We present the accumulating evidence showing the interrelationships of mechanical stress, inflammation, and psychological characteristics on pain. While acute exercise may transiently exacerbate pain symptoms, regular participation in exercise can lower pain severity or prevalence. Aerobic exercise, resistance exercise, or multimodal exercise programs (combination of the two types) can reduce joint pain in young and older obese adults in the range of 14%-71.4% depending on the study design and intervention used. While published attrition rates with regular exercise are high (∼50%), adherence to exercise may be enhanced with modification to exercise including the accumulation of several exercise bouts rather than one long session, reducing joint range of motion, and replacing impact with nonimpact activity. This field would benefit from rigorous comparative efficacy studies of exercise intensity, frequency, and mode on specific and general musculoskeletal pain in young and older obese persons.

Review of Lacrosse-Related Musculoskeletal Injuries in High School and Collegiate Players

Context:

Participation in lacrosse has dramatically increased since 2001. Changes in the game rules, sport equipment, and athlete characteristics have all contributed to the injury patterns in lacrosse over time.

Objective:

A summary of lacrosse-related musculoskeletal injuries.

Data Sources:

Medline, CINAHL, Scopus, and Web of Science were searched for articles relating to the epidemiology and mechanisms of lacrosse injuries in high school and collegiate lacrosse players.

Study Selection:

The search strategy used the following keywords: lacrosse, injury, musculoskeletal, high school, intercollegiate, knee, shoulder, fracture, ankle, foot, concussion, and surveillance. Studies were included if they reported injury risk, injury type, or injury mechanism in high school or collegiate lacrosse players.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data extraction:

Injury type, frequency, and mechanism as well as population were extracted.

Results:

Thirteen cohort studies and an additional 15 case series and reports were included. For all lacrosse players, ankle, knee, and hand/wrist were key sites for acute injury. Among collegiate players, preseasonal play elicits more injuries than seasonal play. Female players incur more noncontact and overuse injuries than male players. Boys have 3 to 5 times the risk for sustaining a fracture compared with girls in competition and practice. Women experienced fewer concussions but more facial fractures than men. Injuries to the foot/ankle, head, face, and wrist/hand more often required surgery in girls than in boys.

Conclusion:

Male players incur more injuries than female players. However, because of the collisional nature of play, more shoulder, arm, and upper leg injuries occur in male players. Fractures to the head and hand occur relatively more frequently in female players. Injury risk can be modified with appropriate training regimens and by respecting the game rules.

Metabolic responses of running shod and barefoot in mid-forefoot runners

BACKGROUND

The purposes of this study were to compare the oxygen cost, metabolic parameters and temporalspatial variables between barefoot and shod running in trained mid-forefoot runners.

METHODS

Experienced runners (N.=21; 30±10.9 years; 16 men) performed two separate 20 minute treadmill running bouts at ~77% of estimated maximal heart rate. Rate of oxygen consumption (VO2), energy cost, fuel use and heart rate (HR) were collected continuously using a portable gas analyzer. Three-dimensional motion capture was used to measure temporalspatial parameters.

RESULTS

Participants ran at a mean self-selected speed of 3.1±0.3 m/s for both conditions, at intensities corresponding to mean HR values of 146 bpm (shod) and 144 bpm (barefoot). Steady State VO2 was not different between the shod and barefoot conditions (39.4± 4.7 mL/kg*min vs. 40±5.2 mL/kg*min, respectively). The total energy expended in the shod and barefoot conditions was 974±134 kJ and 979±142 kJ. The average non-protein respiratory exchange ratios, proportions and amount of fat and carbohydrate used were not different between conditions. Cadence was 2.5% higher and center of gravity vertical displacement was 0.5 cm less for the barefoot condition (P<0.05).

CONCLUSION

In trained mid-forefoot runners experienced with barefoot running, there are not significant metabolic differences between shod and barefoot running conditions. Barefoot running increases cadence and decreases foot contact time and vertical displacement. Experienced participants were likely able to titrate kinematics to standardize energy output and fuel use for a given running distance and speed irrespective of shoe wear.

Setting standards for medically-based running analysis

Setting standards for medically based running analyses is necessary to ensure that runners receive a high-quality service from practitioners. Medical and training history, physical and functional tests, and motion analysis of running at self-selected and faster speeds are key features of a comprehensive analysis. Self-reported history and movement symmetry are critical factors that require follow-up therapy or long-term management. Pain or injury is typically the result of a functional deficit above or below the site along the kinematic chain.

Metabolic, cardiopulmonary, and gait profiles of recently injured and noninjured runners

OBJECTIVE

To examine whether runners recovering from a lower body musculoskeletal injury have different metabolic, cardiopulmonary, and gait responses compared with healthy runners.

DESIGN

Cross-sectional study.

SETTING

Research laboratory at an academic institution.

METHODS

Healthy runners (n = 50) were compared with runners who were recently injured but had returned to running (n = 50). Both groups were participating in similar cross-training modalities such as swimming, weight training, biking, and yoga. Running gait was analyzed on a treadmill using 3-dimensional motion capture, and metabolic and cardiopulmonary measures were captured simultaneously with a portable metabolic analyzer.

MAIN OUTCOME MEASURES

Rate of oxygen consumption, heart rate, ventilation, carbohydrate and fat oxidation values, gait temporospatial parameters and range of motion measures (ROM) in the sagittal plane, energy expenditure, and vertical displacement of the body's center of gravity (COG).

RESULTS

The self-selected running speed was different between the injured and healthy runners (9.7 ± 1.1 km/h and 10.6 ± 1.1 km/h, respectively; P = .038). No significant group differences were noted in any metabolic or cardiopulmonary variable while running at the self-selected or standard speed (13.6 km/h). The vertical displacement of the COG was less in the injured group (8.4 ± 1.4 cm and 8.9 ± 1.4, respectively; P = .044). ROM about the right ankle in the sagittal plane at the self-selected running speed during the gait cycle was less in the injured runners compared with the healthy runners (P < .05).

CONCLUSIONS

Runners with a recent lower body injury who have returned to running have similar cardiopulmonary and metabolic responses to running as healthy runners at the self-selected and standard speeds; this finding may be due in part to participation in cross-training modes that preserve cardiopulmonary and metabolic adaptations. Injured runners may conserve motion by minimizing COG displacement and ankle joint ROM during a gait cycle.

Perioperative and acute care outcomes in morbidly obese patients with acetabular fractures at a Level 1 trauma center

BACKGROUND

Controversy exists regarding obesity-related injury severity and clinical outcomes after orthopedic trauma.

PURPOSE

The purposes of this study were to expand our understanding of the effect of morbid obesity on perioperative and acute care outcomes after acetabular fracture.

METHODS

This was a retrospective review of patients with acetabular fracture after trauma. Non-morbidly obese (BMI < 35 kg/m(2)) and morbidly obese (BMI ≥ 35 kg/m(2); N = 81). Injury severity scores and Glasgow Coma Scale scores (GCS) were collected. Perioperative and acute care outcomes were positioning and operative time, extra fractures, estimated blood loss, complications, hospital charges, ventilator days, transfusions, length of stay (LOS) and discharge destination. Positioning and operative times were longer in morbidly obese patients (p < 0.05). No other differences existed between groups.

CONCLUSIONS

Orthopedic trauma surgeons and care teams can expect similar acute care outcomes in morbidly obese and non-morbidly obese patients with acetabular fracture.

Considerations for initiating and progressing running programs in obese individuals

Running has rapidly increased in popularity and elicits numerous health benefits, including weight loss. At present, no practical guidelines are available for obese persons who wish to start a running program. This article is a narrative review of the emerging evidence of the musculoskeletal factors to consider in obese patients who wish to initiate a running program and increase its intensity. Main program goals should include gradual weight loss, avoidance of injury, and enjoyment of the exercise. Pre-emptive strengthening exercises can improve the strength of the foot and ankle, hip abductor, quadriceps, and trunk to help support the joints bearing the loads before starting a running program. Depending on the presence of comorbid joint pain, nonimpact exercise or walking (on a flat surface, on an incline, and at high intensity) can be used to initiate the program. For progression to running, intensity or mileage increases should be slow and consistent to prevent musculoskeletal injury. A stepwise transition to running at a rate not exceeding 5%-10% of weekly mileage or duration is reasonable for this population. Intermittent walk-jog programs are also attractive for persons who are not able to sustain running for a long period. Musculoskeletal pain should neither carry over to the next day nor be increased the day after exercising. Rest days in between running sessions may help prevent overuse injury. Patients who have undergone bariatric surgery and are now lean can also run, but special foci such as hydration and energy replacement must be considered. In summary, obese persons can run for exercise, provided they follow conservative transitions and progression, schedule rest days, and heed onset of pain symptoms.

Obesity and low back pain: relationships and treatment

SUMMARY Low back pain (LBP) and obesity (defined as BMI ≥30 kg/m(2)) are common problems in the general population. The treatment of LBP is not clearly defined and has variable success in different populations and time-frames. When a person presents with LBP who also meets the criteria for obesity, many questions are raised as to the value of weight-loss treatments and the success and/or safety of usual treatments of LBP, especially exercise. Based on the current medical literature for the treatment of LBP in patients who are obese: there should be attempts at weight loss (nonsurgical or surgical), especially if the person is in the morbidly obese (BMI >40 kg/m(2)) range; all usual forms of exercise and physical therapy treatments are possible and can be beneficial without increased concerns for injury; and, if necessary, invasive treatments such as spinal injections or surgery are potentially beneficial and have similar complication rates to the nonobese population. These options should be offered when medically necessary and appropriate.

Functional impairment in obesity: a focus on knee and back pain

SUMMARY Cross-sectional and longitudinal evidence strongly indicate that obesity is related to physical impairment and joint pain, particularly in the lumbar spine, sacroiliac and knee joints. What is most disturbing is that obese children under 15 years are now reporting joint pain and cannot perform functional tasks as well as their nonobese counterparts. As the prevalence of obesity rises, so do the rates of musculoskeletal disease and physical dysfunction. Functional tasks that involve supporting or transferring body weight are typically painful and difficult to perform. Of most concern is that some of these tasks are simply impossible depending on the severity of obesity. As a consequence, the individual's quality of life suffers. A BMI of 35 kg/m(2) is emerging as the threshold at which functional impairment rates rise dramatically. To restore functional independence and optimize functional gains over the long term, a combination of treatments for the obese patient with joint pain may be effective. The initial use of physical therapy, pain medications or joint viscosupplementation, coupled with diet, exercise, or bariatric surgery are options for weight loss and reduction of pain symptoms. Irrespective of age, weight loss can reduce or eliminate joint pain. As body weight is reduced, so should the reliance on medication with a concomitant improvement in functional mobility.

Acute Effects of Enhanced Eccentric and Concentric Resistance Exercise on Metabolism and Inflammation

This study compared the metabolic, cardiopulmonary and inflammatory responses of novel acute machine based concentrically-focused resistance exercise (CON RX) and eccentrically-focused resistance exercise (ECC RX). Twenty healthy adults (26.8 ± 5.9 yrs; 25.4 ± 4.0 kg/m²) performed two work-matched RX exercise sessions. Cardiopulmonary responses, rating of perceived exertion (RPE), soreness, oxygen consumption; (VO2) were collected during each session. Blood lactate and levels of inflammatory cytokines interleukin-1 alpha (IL1α), interleukin-6 (IL6) and tumor necrosis factor-alpha (TNFα) were analyzed pre, post ad 24 hours post-exercise. HR were higher (5-15bpm) during ECC RX (p<.05). Soreness ratings were consistently higher post-ECC RX compared to CON RX. VO2 area under the curve was higher during ECC than CON (31,905 ml/kg/min vs 25,864 ml/kg/min; p<.0001). Post-ECC RX, TNFα levels increased compared to CON RX 23.2 ± 23.9% versus 6.3 ± 16.2% ( p=.021). ECC RX induced greater metabolic, cardiopulmonary and soreness responses compared to matched CON RX. This may be due to recruitment of additional stabilizer muscles and metabolic stress during the ECC RX. These factors should be considered when designing ECC RX programs particularly for untrained persons, older adults or those with history of cardiovascular disease.

Back strength predicts walking improvement in obese, older adults with chronic low back pain

OBJECTIVE

To compare the effects of 4 months of isolated lumbar resistance exercise and total body resistance exercise on walking performance in obese, older adults with chronic low back pain. A secondary analysis examined whether responsiveness to training modulated walking improvement.

DESIGN

Randomized, controlled trial.

SETTING

Research laboratory affiliated with tertiary care facility.

METHODS AND INTERVENTION

Participants (N = 49; 60-85 years) were randomized into a 4-month resistance exercise intervention (TOTRX), lumbar extensor exercise intervention (LEXT), or a control group (CON).

MAIN OUTCOME MEASUREMENTS

Walking performance, maximal low back strength and leg strength, and average resting and low back pain severity score (from an 11-point numerical pain rating scale; NRSpain) were collected at baseline and month 4.

RESULTS

The TOTRX and LEXT improved lumbar extensor strength relative to CON, and the TOTRX (P < .05). NRSpain scores at month 4 were lowest in the TOTRX group compared with the LEXT and CON groups, respectively (2.0 ± 1.7 points vs 3.7 ± 2.6 points and 4.6 ± 2.4 points; P < .006). A total of 53% and 67% of participants in the TOTRX and LEXT groups were responders who made lumbar extensor strength gains that achieved ≥20% greater than baseline values. Although the TOTRX demonstrated the greatest improvement in walking endurance among the intervention groups, this did not reach significance (10.1 ± 12.2% improvement in TOTRX vs 7.4 ± 30.0% LEXT and -1.7 ± 17.4% CON; P = .11). Gait speed increased most in the TOTRX (9.0 ± 13.5%) compared with the LEXT and CON groups (P < .05). The change in lumbar extensor strength explained 10.6% of the variance of the regression model for the change in walking endurance (P = .024).

CONCLUSIONS

The use of LEXT and TOTRX produced similar modest improvements in patients' walking endurance. Lumbar extensor strength gain compared with leg strength gain is a moderate but important contributor to walking endurance in obese older adults with chronic low back pain. Responders to resistance exercise programs (event those with only lumbar extension exercise) who make at least a 20% improvement in strength can expect better improvement in walking endurance than those who do not achieve this strength improvement.

Hyaluronic Acid (HA) Viscosupplementation on Synovial Fluid Inflammation in Knee Osteoarthritis: A Pilot Study

OBJECTIVE

This study examined the changes in synovial fluid levels of cytokines, oxidative stress and viscosity six months after intraarticular hyaluronic acid (HA) treatment in adults and elderly adults with knee osteoarthritis (OA).

DESIGN

This was a prospective, repeated-measures study design in which patients with knee OA were administered 1% sodium hyaluronate. Patients (N=28) were stratified by age (adults, 50-64 years and elderly adults, ≥65 years). Ambulatory knee pain values and self-reported physical activity were collected at baseline and month six.

MATERIALS AND METHODS

Knee synovial fluid aspirates were collected at baseline and at six months. Fluid samples were analyzed for pro-inflammatory cytokines (interleukins 1β, 6,8,12, tumor necrosis factor-α, monocyte chemotactic protein), anti-inflammatory cytokines (interleukins 4, 10 13), oxidative stress (4-hydroxynonenal) and viscosity at two different physiological shear speeds 2.5Hz and 5Hz.

RESULTS

HA improved ambulatory knee pain in adults and elderly groups by month six, but adults reported less knee pain-related interference with participation in exercise than elderly adults. A greater reduction in TNF-α occurred in adults compared to elderly adults (-95.8% ± 7.1% vs 19.2% ± 83.8%, respectively; p=.044). Fluid tended to improve at both shear speeds in adults compared to the elderly adults. The reduction in pain severity correlated with the change in IL-1β levels by month six (r= -.566; p=.044).

CONCLUSION

Reduction of knee pain might be due to improvements in synovial fluid viscosity and inflammation. Cartilage preservation may be dependent on how cytokine, oxidative stress profiles and viscosity change over time.

Associations of self-report measures with gait, range of motion and proprioception in patients with lumbar spinal stenosis

INTRODUCTION

Spinal stenosis is defined as neurogenic claudication due to narrowing of the spinal canal lumen diameter. As the disease progresses, ambulation and gait may be impaired. Self-report measures are routinely used in the clinical setting to capture data related to lumbar pain symptoms, function and perceived disability. The associations between self-report measures and objective measures of physical function in patients with lumbar spinal stenosis are not well characterized. The purpose of this study was to determine the correlation between self-reported assessments of function with objective biomechanical measures of function.

METHODS

25 subjects were enrolled in this study. Subjects completed self-report questionnaires and biomechanical assessments of gait analysis, lumbar 3D ROM and lumbar proprioception. Correlations were determined between self-report measures and biomechanical data.

RESULTS

The Oswestry Disability Index (ODI) was strongly correlated with stride length and gait velocity and weakly correlated with base of support. ODI was also weakly correlated with left lateral bending proprioception but not right lateral bending. The SF12 was not significantly correlated with any of the biomechanical measurements. Pain scores were weakly correlated with velocity, and base of support, and had no correlation any of the other biomechanical measures.

DISCUSSION

There is a strong correlation between gait parameters and functional disability as measured with the ODI. Quantified gait analysis can be a useful tool to evaluate patients with lumbar spinal stenosis and to assess the outcomes of treatments on this group of patients.

Outpatient rehabilitation outcomes in obese patients with orthopedic conditions

BACKGROUND

Obesity is related to the development of functional and mobility impairment, musculoskeletal pain and orthopedic problems. Irrespective of age, obese children and adults have impaired walking capacity and body transfer ability, and difficulties navigating obstacle courses or community spaces. Obesity is related to relative strength deficits, musculoskeletal pain, kinesiophobia, low self-efficacy and a decline in quality of life.

AIM

This review provides an update of the available evidence for the efficacy of outpatient rehabilitation programs for the treatment of disabling obesity.

RESULTS

Outpatient rehabilitation programs can effectively improve muscle strength, self-confidence and physical function. Key rehabilitation components should include aerobic exercise (AX), resistance exercise (RX) and cognitive strategies to cope with the unique challenges posed by obesity. Available high quality evidence indicates that 3-18 month rehabilitation programs that included aerobic and strengthening exercise (2-3 days per week) with caloric restriction (typically 500-750 kcal deficit/ day), elicited the best changes in functional performance measures compared with exercise or diet alone.

CONCLUSION

Comprehensive outpatient rehabilitation interventions coupled with diet can catalyze lifestyle patterns that improve and preserve physical function over the life span.

"Functional pain," functional outcomes, and quality of life after hyaluronic acid intra-articular injection for knee osteoarthritis

OBJECTIVE

To compare the effect of hyaluronic acid (HA) intra-articular knee injections on pain and functional outcomes in persons with knee osteoarthritis (OA) over 6 months, and to determine whether or not changes in functional pain are related to improvements in quality of life.

DESIGN

A prospective cohort study.

SETTING

A research laboratory in an academic medical center.

PARTICIPANTS

Patients with knee OA (N = 53) who were receiving medical care for OA.

INTERVENTIONS

Intra-articular knee injections of HA (3 injections, each separated by 1 week) and a comparative noninjection group.

MAIN OUTCOME MEASUREMENTS

Functional pain and outcomes assessments during chair rise, stair climbing, and a 6-minute walking test (by using 0-10 point numerical pain ratings during each test); gait parameters; Medical Outcomes Short Form-36 (SF-36) scores and subscores; the Western Ontario McMaster University Osteoarthritis Index (WOMAC).

RESULTS

Six months after HA, the completion times for the chair rise and stair climb tasks, and the distance covered during the 6-minute walk were not different between the groups. However, functional pain ratings during stair climbing decreased in the HA-treated group (P = .05). Six-month changes in gait velocity, cadence, stride length, step length, and the percentage of the gait cycle spent in single support were all higher after HA injection at month 6 (all P < .05). Significant group-by-time interactions existed for total WOMAC scores. SF-36 Vitality subscores improved by 13%, and Role Physical scores were higher in patients treated with HA injection compared with participants in the noninjection group (P < .05). Regression analyses revealed that changes in the functional pain measures did not correspond with SF-36 scores.

CONCLUSIONS

HA is associated with lower functional pain severity, with minimal impact on functional test scores. We interpreted this finding to represent an increase in the quality of the movement and functional activity. The change in functional pain did not correspond to changes in SF-36 quality-of-life scores.

Resistance exercise for knee osteoarthritis

The initiation, progression, and severity of knee osteoarthritis (OA) have been associated with decreased muscular strength and alterations in joint biomechanics. Chronic OA pain may lead to anxiety, depression, fear of movement, and poor psychological outlook. The fear of movement may prevent participation in exercise and social events, which could lead to further physical and social isolation. Resistance exercise (RX) has been shown to be an effective intervention both for decreasing pain and improving physical function and self-efficacy. RX may restore muscle strength and joint mechanics while improving physical function. RX also may normalize muscle firing patterns and joint biomechanics, leading to reductions in joint pain and cartilage degradation. These physical adaptations could lead to improved self-efficacy and decreased anxiety and depression. RX can be prescribed and performed by patients across the spectrum of OA severity. When designing and implementing an RX program for a patient with knee OA, one should consider both the degree of OA severity and the level of pain. RX, either in the home or at a fitness facility, is an important component of a comprehensive regimen designed to offset the physical and psychological limitations associated with knee OA. Unique considerations for this population include (1) monitoring pain during and after exercise, (2) providing days of rest when disease flares occur, and (3) infusing variety into the exercise regimen to encourage adherence.

The aging musculoskeletal system and obesity-related considerations with exercise

Advancing age and adiposity contribute to musculoskeletal degenerative diseases and the development of sarcopenic obesity. The etiology of muscle loss is multifactorial, and includes inflammation, oxidative stress and hormonal changes, and is worsened by activity avoidance due to fear of pain. The risk for mobility disability and functional impairment rises with severity of obesity in the older adult. Performance measures of walking distance, walking speed, chair rise, stair climb, body transfers and ability to navigate obstacles on a course are adversely affected in this population, and this reflects decline in daily physical functioning. Exercise training is an ideal intervention to counteract the effects of aging and obesity. The 18 randomized controlled trials of exercise studies with or without diet components reviewed here indicate that 3-18 month programs that included aerobic and strengthening exercise (2-3 days per week) with caloric restriction (typically 750 kcal deficit/day), induced the greatest change in functional performance measures compared with exercise or diet alone. Importantly, resistance exercise attenuates muscle mass loss with the interventions. These interventions can also combat factors that invoke sarcopenia, including inflammation, oxidative stress and insulin resistance. Therefore, regular multimodal exercise coupled with diet appears to be very effective for counteracting sarocpenic obesity and improving mobility and function in the older, obese adult.

Obesity and weight loss in the treatment and prevention of osteoarthritis

Obesity is associated with an increasing prevalence of musculoskeletal complaints and pain. Obesity is a major risk factor for osteoarthritis (OA), and pain can manifest in load-bearing and nonload-bearing joints. The lumbar spine and the knee are 2 primary sites for pain onset in the obese patient. Irrespective of the weight loss method, reduction of body fat can lower the mechanical and inflammatory stressors that contribute to OA. Single or combined methods of weight loss including exercise, dietary modification, medications, and bariatric surgery are associated with lower joint pain and increased physical function. Methods of weight loss or maintenance in early years may reduce the life exposure of joints to the obesity induced stressors on load bearing joints.

Obesity and long term functional outcomes following elective total hip replacement

Introduction

Obesity rates continue to rise and more total hip arthroplasty procedures are being performed in progressively younger, obese patients. Hence, maintenance of long term physical function will become very important for quality of life, functional independence and hip prosthesis survival. Presently, there are no reviews of the long term efficacy of total hip arthroplasty on physical function. This review: 1) synopsized available data regarding obesity effects on long term functional outcomes after total hip arthroplasty, and 2) suggested future directions for research.

Methods

A literature search was conducted from 1965 to January of 2011 for studies that evaluated long term functional outcomes at one year or longer after THA in obese (body mass index values ≥30 kg/m²) and non-obese patients (body mass index <30 kg/m²).

Results

Five retrospective studies and 18 prospective studies were identified as those that assessed physical function before surgery out to ≥ one year after total hip arthroplasty. Study sample sizes ranged from 108–18,968 and followed patients from one to twenty years. Total hip arthroplasty confers significant pain reduction and improvement in quality of life irrespective of body mass index. Functional improvement occurred after total hip arthroplasty among all studies, but obese patients generally did not attain the same level of physical function by the follow-up time point.

Discussion

Uncontrolled obesity after total hip arthroplasty is related to worsening of comorbidities and excessive health care costs over the long term. Aggressive and sustainable rehabilitation strategies that include physical exercise, psychosocial components and behavior modification may be highly useful in maximizing and maintaining weight loss after total hip arthroplasty.

Subcutaneous methylnaltrexone for treatment of acute opioid-induced constipation: phase 2 study in rehabilitation after orthopedic surgery

BACKGROUND

Methylnaltrexone has been shown to be effective for treating opioid-induced constipation (OIC) in chronic settings, but its effects on acute OIC have not been studied.

OBJECTIVE

To assess safety and efficacy of subcutaneous methylnaltrexone in patients with acute OIC after orthopedic procedures.

DESIGN

Double-blind, randomized, parallel-group, placebo-controlled, hypothesis-generating phase 2 study.

SETTING

Sixteen US hospitals and rehabilitation facilities.

PATIENTS

Adult patients with acute OIC after orthopedic surgical procedure, expected to require opioids for at least 7 days postrandomization.

INTERVENTIONS

Patients received once-daily subcutaneous methylnaltrexone 12 mg or placebo for up to 4 or 7 days.

MEASUREMENTS

All endpoints were exploratory and included the percentage of patients achieving laxation within 2 and 4 hours of first dose and time to laxation.

RESULTS

Thirty-three patients received at least 1 dose of study drug (methylnaltrexone, n = 18; placebo, n = 15). Within 2 and 4 hours, significantly more patients receiving methylnaltrexone achieved laxation (2 hours: 33.3% vs 0%, P = 0.021; 4 hours: 38.9% vs 6.7%, P = 0.046) compared with placebo. Time to laxation was significantly shorter with methylnaltrexone (median = 15.8 hours) versus placebo (median = 50.9 hours), P = 0.0197. The most common adverse events related to the gastrointestinal tract. Pain scores remained stable and were similar to those of placebo, and signs and symptoms of opioid withdrawal did not emerge in patients receiving methylnaltrexone.

CONCLUSIONS

Methylnaltrexone was generally well tolerated and was active in inducing laxation in this study of patients experiencing acute OIC following orthopedic surgery.

Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery

BACKGROUND

Joint pain is a common musculoskeletal complaint of morbidly obese patients that can result in gait abnormalities, perceived mobility limitations, and declining quality of life (QOL). It is not yet known whether weight loss 3 months after bariatric surgery can induce favorable changes in joint pain, gait, perceived mobility, and QOL. Our objectives were to examine whether participants who had undergone bariatric surgery (n = 25; laparoscopic Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding) demonstrate improvements in joint pain, gait (speed, stride/step length, width of base of support, toe angles, single/double support, swing and stance time, functional ambulatory profile), mobility, and QOL by 3 months compared with nonsurgical controls (n = 20). The setting was an orthopedics laboratory at a university hospital in the United States.

METHODS

The present study was a prospective, comparative study. Numeric pain scales (indicating the presence and severity of pain), mobility-related surveys, and the Medical Outcomes Study short-form 36-item questionnaire (SF-36) were completed, and gait and walking speed were assessed at baseline and at month 3.

RESULTS

The bariatric group lost an average of 21.6 ± 7.7 kg. Significant differences existed between the 2 groups at month 3 in step length, heel to heel base of support, and the percentage of time spent in single and double support during the gait cycle (all P <.05). The severity of low back pain and knee pain decreased by 54% and 34%, respectively, with no changes in the control group (P = .05). The walking speed increased by 15% in the bariatric group (108-123 cm/s; P <.05) but not in the control group. Compared with the control group, fewer bariatric patients perceived limitations with walking and stair climbing by month 3. The bariatric group had a 4.8-cm increase in step length, 2.6% increase in single support time during the gait cycle, and 2.5-cm reduction in the base of support (all P <.05). The SF-36 physical component scores increased 11.8 points in the bariatric group compared with the control group, which showed no improvement by month 3 (P <.0001).

CONCLUSIONS

Improvements in some, but not all, gait parameters, walking speed, and QOL and of perceived functional limitations occur by 3 months after a bariatric procedure.